Ulcerative Tonsillitis or Vincent's stom atitis varies, even when cases give the same bacteriologic results. It may give a picture so like to that of pharyngeal diphtheria that it is often called diphtheroid angina. In such a case there appears on one, usually the right, tonsil, a pseudomembrane one to two mm. thick, which may spread to the pillars and even to the soft palate, its removal causing bleeding and loss of tissue. The flow of saliva is increased and the breath has a foul odor. There is moderate swelling of the regional lymph-glands, usually of the affected side, but with no tendency to sup purate. Aside from anorexia, there is little general disturbance. The temperature may be slightly elevated, or depressed. The throat becomes clear in a few days or the necrosis may be deep enough to cause an ulcer filled with a necrotic mass; septic complications may result from this or diphtheria may develop secondarily.
The disease is distinguished from diphtheria especially by the con sistency of the membrane. It is rather firm but not holding together in one piece; it consists of granular and flaky detritus and also contains remains of nuclei, fibrin-threads and numerous bacteria, especially the Bacillus fusiformis, and spirilla (Bernheim, Vincent, Dopter).
Herpetic is occasionally seen in children, coming on with a preliminary period of moderately high fever for one to three days, with severe headache. Then herpes form on the pharyngeal mu cous membrane and break clown quickly. After the vesicles have rup tured there remain yellowish depressions surrounded with an inflamma tory ring, and in these a whitish deposit may occur. If these run together a similarity to diphtheria may arise. The long initial fever, the intense headache, the multiform appearances of the ulcers and the development of fresh crops of herpes on the mucous membrane help in differentiating the process.
The development of herpes facialis is not distinctive ; for it is a fre quent condition, in children, well or sick, and may also he present in diphtheria.
Membrane after Tonsillotomy, Cauterization or diphtheria-like membrane is seen after tonsillototny. A mistaken diag nosis is possible only through ignorance of the history. Yet care must be exercised, for secondary infection with diphtheria is a possibility. Epi thelial necrosis and subsequent ulcer-formation may follow cauterization of the mucous membrane of the mouth or throat in circumscribed spots. The history and the attendant circumstances clear up these eases.
Affections of the Pharynx in Scarlet this disease the picture may recall that of lacunar angina or of punctate diphtheria, or, as in diphtheria, pseudomembranes and a tendency to necrosis may develop. In the first case, before the eruption has appeared, the onset is with vomiting (rare in diphtheria), and high fever; and the contrast of the dusky redness of the pharynx with the snow-whiteness of the tongue, and later after shedding of the coating, the characteristic strawberry appearance, all point to scarlet fever.
Diphtheroid scarlatina, which occasionally does not develop from the simple angina until the rash is fading differs from diphtheria in its limited extent—as a rule not going beyond the tonsils, and almost never attacking the larynx—in the much greater tendency to tissue-necrosis, in the very intense affection of the glands, in the absence of paralysis and in the appearance of lamellar desquamation.
Examination of the urine may furnish important aids to diagnosis. The test for the diazo reaction in diphtheria, except in the malignant forms, is negative, while in scarlet fever it. is positive in 40 per cent. of
the cases. 1:robilinuria and indicanuria are almost constant in diph theria and are rare in scarlet fever (I,abbe).
ordinary aplithte the symmetrical ulcers on the hard palate, seen in newborn and young infants, known as Bednar's aphtha', may under some conditions resemble diphtheria very strongly. They are caused by lesions of the epithelium in suckling and swallowing or by rough cleansing. In athreptic infants these small circumscribed lesions may, by the entrance of bacteria, change to sup purating, sharply limited ulcers, which may progress in a symmetrical butterfly-fashion and cover nearly the whole of the palate. Membrane.• formation may also occur in places. In the deposit are found detritus,. pus cells and a great mass of the most varied forms of bacteria, espe, cially streptococci and staphylococci. The temperature is normal or slightly elevated, and the breath has a cheesy odor.
The ulcers may be the starting-point of a septic infection; on the other hand similar necrosis of the oral and pharyngeal mucous membrane may appear in the course of an existing septicaemia (Baginsky) While it is easy to differentiate these ulcers from diphtheria by their characteristic form and the pultaceous deposit, it is difficult to do so in the much rarer cases in which there is the fibrinous deposit on and in the mucous membrane with the formation of tough, elastic exudates, which are constantly renewed and which lead to necrosis, the process showing a tendency to spread in the same form to the mouth as well as to the respiratory and digestive tracts (pseudodiphthcritic septicamtia, Epstein). Cases running such a course, however, bear the plain evi dences of septicaemia in themselves and may be recognized as such hy the clinical features. The resemblance to diphtheria. is even greater when coexistent congenital struma or thy mus-hyperplasia causes more or less severe symptoms of stenosis (Brecclj).
is a special form of stomatitis caused by the thrush fungus (Monilia candida). The fungus penetrates the epithelium and sets up an inflammation of the mucous membrane, showing itself in irritation. swelling and pain. The thrush colonies arc round and usually granular, and if their growth is not checked, they may run together and cover the greater part of the mucous membrane with a thick, dirty white layer. If, as is the exception, the thrush membrane is localized on the isthmus of the faeces, it may then happen through the di fliculty of inspecting this part of an infant's throat that the judgment of the physician inclines to diphtheria, especially if coryza and hoarseness ex ist, as is frequently the case with atropic infants, with fever from sonic cause or other. But careful inspection of the mouth-cavity will soon show characteristic isolated thrush-colonies and, at any rate, the micro scopic examination will correct the error by showing the presence of mycelium, gonidia and spores.
Syphilitic Stomatitis.—In hereditary syphilis, mucous patches may rarely occur in the mouth in the form of a whitish gray, round infiltration, sharply limited and somewhat elevated on a more or less deeply reddened base. Through considerable extension and localiza tion on the tonsils and palate, they may resemble diphtheritic pseudo membranes, and so much the more if syphilitic coryza and laryngitis are present. And yet the patches may show plainly the presence of fissures, while all the accompaniments of diphtheria are absent, and other symp toms of lees may usually be elicited.